Melvin P. Bubrick

Malignancy, mortality, and medicosurgical management of Clostridium septicum infection

BACKGROUND Necrotizing Clostridium septicum infections (CSI) have a strong association with malignancy or immunosuppression. To clarify this relationship and determine how it impacted mortality, the experience with CSI at a single institution was reviewed. METHODS Records of all patients admitted to our hospital with culture proven clostridial infection from 1966 through 1993 were reviewed. RESULTS Among patients presenting with clinical gas gangrene, 281 had culture proven clostridial infection and 32 (11.4%) had CSI. The mortality among CSI patients was 56%, whereas 26% of all patients with clostridial infections died (p = 0.001). An associated malignancy was found in 50% of patients with CSI, whereas this was seen in only 11% of patients with other clostridial infections (p = 0.0001 for CSI versus clostridial infection overall). The remaining patients with spontaneous CSI all had evidence of immunosuppression. CONCLUSIONS The high mortality and likelihood of associated malignancy or hematologic disease underscore the importance of a high index of suspicion and the need to search for and treat associated conditions in all patients with CSI.

Mortality from ischemic colitis

Thirty-nine hospital-based cases of ischemic colitis were reviewed. There were 18 males and 21 females. Average age was 68.7 years (range, 18 to 92 years). Associated diseases among 13 patients younger than 65 included renal failure in seven patients and hematologic, vasculitic, or collagen vascular diseases in four. In 26 patients 65 or older, congestive heart failure was seen in 13, vascular disease in eight, and previous aortic surgery in four. Nineteen patients were treated nonsurgically and 8 died (42 percent mortality). Twenty patients (51 percent) underwent surgery: 18 had resection with colostomy or ileostomy and two had resection with reanastomosis; one patient underwent laparotomy followed by second-look exploration without resection. Thirteen of the 20 surgical patients died (65 percent mortality). Both patients who underwent reanastomosis died of sepsis. The data show a close association between ischemic colitis and a number of serious systemic diseases including renal failure, arteriosclerotic heart and vascular disease, and hematologic, vasculitic, and connective-tissue disease. A predilection for the right colon and sigmoid colon and splenic flexure was seen. A formidable mortality rate (53 percent) was found among patients treated both surgically and nonsurgically.

Comparison of the Valtrac biofragmentable anastomosis ring with conventional suture and stapled anastomosis in colon surgery

In a randomized, prospective study of 438 patients, the safety and efficacy of the Valtrac biofragmentable anastomotic ring (BAR) was compared with stapling and with conventional suture techniques. There was no significant difference in the morbidity, mortality, and clinical course of the patients. The BAR can effect reestablishment of intestinal continuity somewhat more rapidly, but its major advantage is its uniform applicability to all areas of the intestinal tract, except the low rectum.

Prospective, randomized trial of the biofragmentable anastomosis ring

A randomized trial was undertaken to compare the biofragmental anastomotic ring (BAR) with conventional intraperitoneal colorectal anastomotic techniques. Patients were randomized into one of two schemes: BAR versus sutured or BAR versus stapled anastomosis. There were 782 patients entered into the study and 283 patients (36%) had a sutured anastomosis, 104 patients (13%) had a stapled anastomosis, and 395 (51%) had the BAR. Comparison of the BAR with combined suture and stapled controls revealed no significant differences in wound complication, abscess rate, bleeding, anastomotic leaks, ileus, obstruction, or deaths. There were no differences in return of bowel function, return to normal diet, or hospital stay. Intraoperative difficulties occurred in 46 BAR patients (17%), and this was significantly higher (p less than 0.001) than for sutured (3%) but not for stapled anastomoses (11%). The occurrence of these problems did not adversely effect the outcome. The data suggest that the BAR is a safe, satisfactory alternative to sutured or stapled colorectal anastomoses.

Aminopyrine breath test predicts surgical risk for patients with liver disease.

To determine whether the [14C] aminopyrine breath test (ABT) predicts surgical risk in patients with liver disease, it was obtained prior to various surgeries in 38 patients with known or suspected liver disease. A modified Childs classification was also determined. Six of the seven operative deaths (three Childs A, two B, two C) had ABTs < 2.3%, while 30 of 31 survivors (24 Childs A, seven B) had ABTs > 2.3% (p < 0.000018). Seven of the 16 patients with normal ABTs had biopsy-proven cirrhosis and had postoperative courses indistinguishable from the remainder of the group. We conclude that surgery in patients with ABTs < 2.3% is associated with extremely high mortality. In addition, cirrhotics with normal ABTs tolerate elective surgery well.

Anatomical and Morphological Evaluation of Pacemaker Lead Compression

In recent years, pacemaker lead failure due to compressive damage has been reported with increasing frequency. To document the mechanism of this failure, we evaluated explanted mechanically damaged leads with electrical testing, optical microscopy, and in some cases, scanning electron microscopy (SEM) In addition, we performed an autopsy study to measure the compressive loads on catheters placed percutaneously through the costoclavicular angle, as well as by cephalic cutdown. Of the 49 explanted compression damaged leads with enough clinical data for analysis, all had been placed by percutaneous subclavian puncture. Our autopsy data confirmed the significant increase in pressures generated in the costoclavicular angle for medial percutaneous subclavian catheterization (126 ± 26 mmHg) compared to a more lateral percutaneous subclavian puncture (63 ± 15 mmHg) or a cephalic cutdown (38 ± 13 mmHg) (P < 0.01). In vivo coil compression testing documented loads up to 100 pounds per linear inch of coil and a compressive morphology by SEM identical to that seen in the clinical explants. Pacemaker leads appear to be susceptible to compression damage when placed by subclavian venipuncture. When possible, leads should be placed such that they avoid the tight costoclavicular angle.

Experience with colonic volvulus.

Fifty-eight cases of colonic volvulus were reviewed including 30 cases of sigmoid volvulus, 27 cases of cecal volvulus, and 1 of transverse colon volvulus. Decompression procedures were attempted in 31 instances of sigmoid volvulus in 27 patients and were successful 25 times (81 percent). Seven patients with sigmoid volvulus did not undergo surgery and of those, two died of unrelated causes, one was lost to follow-up, one was well, and three had recurrent volvulus. Twenty-four operations were performed on 23 patients and there were three deaths (13 percent mortality). There was one recurrence in two patients who underwent simple detorsion. Chronic large-bowel motility disturbances were a persistent problem in 9 of 20 (45 percent) surgical survivors. Among 27 instances of cecal volvulus, one was reduced by contrast enema and ten endoscopic attempts at decompression were unsuccessful. Twenty-six operations were done and there were four operative deaths (15 percent mortality). There were no recurrences. Large-bowel motility disorders were noted in follow-up in 3 of 22 patients (14 percent). Overall there were 10 deaths in 58 patients for a 17 percent mortality rate. These data support the importance of endoscopic decompression for sigmoid volvulus but not for cecal volvulus. Definitive treatment of both forms of volvulus should include assessment of colonic motility.

PRE-EXPOSURE TO HYPOXIA OR SEPTIC STIMULI DIFFERENTIALLY REGULATES ENDOTOXIN RELEASE OF TUMOR NECROSIS FACTOR, INTERLEUKIN-6, INTERLEUKIN-1, PROSTAGLANDIN E2, NITRIC OXIDE, AND SUPEROXIDE BY MACROPHAGES

UNLABELLED Shock states with resulting inadequate cellular oxygen delivery may contribute to macrophage (M phi) activation or dysregulation. In this study we compared the effects of transient anoxia and endotoxin pretreatment (LPS1) on M phi mediator release with a second endotoxin stimulus (LPS2). METHODS In vitro cultures of murine peritoneal exudate M phi were exposed to 2 hours of hypoxic or normoxic conditions, then incubated 22 hours under identical normoxic conditions +/- 10 ng/mL of LPS1 pretreatment. During the final 24 hours all M phis were exposed to a range of LPS2 concentrations. The M phi supernatants were assayed for tumor necrosis factor (TNF), interleukin 1 (IL-1), interleukin 6 (IL-6), prostaglandin E2 (PGE2), nitric oxide (NO), and superoxide release. RESULTS LPS1 markedly inhibited M phi TNF release by LPS2, but hypoxia had no effect on LPS2-triggered TNF release. Hypoxia increased M phi IL-6 production in the absence of LPS1, but inhibited the LPS1 augmentation seen under normoxic conditions. Pretreatment with LPS1 increased NO production from LPS2 under normoxic conditions, but hypoxia inhibited this effect. Superoxide production increased by LPS1 under normoxic conditions, but hypoxia significantly inhibited superoxide release. CONCLUSIONS The effects of transient anoxic exposure on LPS2-triggered M phi function are markedly different from the effects of pretreatment with septic stimuli (LPS1).

The relationship of hemorrhoids to portal hypertension

Records of 188 patients with documented portal hypertension were reviewed to determine the incidence of hemorrhoids as well as bleeding complications associated with this condition. The incidence of hemorrhoids among these patients was not increased compared to the normal population. Six of the patients with portal hypertension did, however, bleed massively from hemorrhoids. Elevated portal venous pressure is an important factor in those patients having severe hemorrhoidal bleeding. The presence of coagulation defects may also be of considerable importance.

Endotoxin Pretreatment Of Human Monocytes Alters Subsequent Endotoxin-triggered Release Of Inflammatory Mediators

In trauma or sepsis, monocytes and macrophages release mediators such as tumor necrosis factor (TNF), interleukin-1 (IL-1), interleukin-6 (IL-6), and prostaglandin E2 (PGE2). Although patients may be exposed to more than one stimulus, the effect of repetitive endotoxin (LPS) stimulation on human monocytes is poorly characterized. Human peripheral blood monocytes obtained from healthy volunteers were pretreated with endotoxin (LPS1) for 24 h. Cultures were then restimulated for 24 h with a second, activating LPS stimulus (LPS2) at various concentrations and supernatant mediators (TNF, IL-1, IL-6, and PGE2) measured. Serum cytokine levels of normal monocyte donors were compared to basal and LPS-stimulated cytokine release of their monocytes in vitro. LPS2 increased all mediators in a dose-dependent manner in the absence of LPS1 pretreatment. LPS1 significantly increased LPS2-triggered monocyte secretion of IL-1, IL-6, and PGE2, but inhibited TNF release. Cell-associated TNF and IL-1 were also inhibited and enhanced in parallel with supernatant levels of the respective cytokines. Serum cytokine levels were low, showed wide variation, and correlated poorly with in vitro LPS-triggered cytokine production. Human monocyte mediator production is differentially regulated by endotoxin pretreatment. Provocative in vitro testing of monocytes could identify prior LPS exposure and may be more useful than serum cytokine measurements.